May 20, 2025 • 27 mins
In this episode, leading experts identify key elements of an obstetric and postpartum history that may signal later life cardiovascular risk. Learn about relevant tools and crucial strategies to guide cardiovascular disease prevention efforts.
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Episode Transcript
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(00:14):
Hi, I
am DoctorAnn Celi, and I'm coming in to you
from Brigham and Women's Hospitaland Harvard Medical School here in Boston.
And today I'm talking about sort ofhow we can use obstetric histories
to really capitalize on addressinglonger term cardiovascular risk.
So I really like to think about thisas sort of thinking beyond birth
(00:35):
and longer term opportunitiesto improve cardiometabolic health.
And this project was, supported
by funding from Merckthrough its Merck for mothers program.
The recommendations and opinionspresented by our guest speakers
may not represent the official positionof the American Heart Association.
The materials are for educational purposesonly and do not constitute
(00:56):
an endorsementor instruction by AHA or ASA.
The AHA / ASA doesnot endorse any product or device.
I have nothing to disclose.
And Marika Hamilton, who's my patient,who's also going to appear on this,
has nothing to disclose either.
So our learning objectives for todayinclude, we're going to be talking about
the importance of an obstetric history,what it means suggested questions
(01:19):
and conversation startersto help obtain this history from patients.
We're going to try to identify the keyelements of the obstetric history
that signal later life
cardiovascular risk to guidecardiovascular disease prevention efforts.
Recognize the role of disparitiesand social determinants of health
during care transition, and develop
strategies to connect patientsto available resources.
(01:42):
Incorporate obtaining an obstetric historyand counseling strategies to decrease
cardiac anabolic risk
by a lifestyle change, including toolslike Life's Essential eight
and a routine visit and the months, years,and decades after pregnancy.
So this is not ACOG approved,but these are acronyms that many
physicians, caregivers, doulas,community health workers, nurses see.
(02:03):
And it can seem a little bitlike alphabet soup
because there's just so many lettersand we don't really understand
where they come from.
So I was going to hope to sort of talk
about some of the obstetric lingo,to be able to better understand
and obstetrical historyif you're reading charts.
And also just to geta better understanding of what
we're looking for and what we needin terms of the care for our patients.
(02:24):
So it's important to try to understanda patient's birth story.
If they've if they're somebodywho's given birth at their Paris, and,
one of the one of the important earlythings is like, how far along were they
and their pregnancyand what was their gestational age?
And was the baby did the babygo to the neonatal intensive care unit,
which, is a marker of sort of diseaselevel?
(02:46):
You know, if somebody was born early,a baby was born early.
That's obviously,you know, incredibly concerning
and may have eithera fetal or maternal reason for that.
And if the baby is in the queue,
then that's really sort of a markerof what the birth outcome was.
And that's something,you know, to obviously,
the ultimate product of a pregnancyis we want a healthy baby.
So look at baby'soutcome is quite important.
The next thing we want to look atis, was the labor, induced or was it
(03:11):
spontaneous or was it scheduled, like,you know, a scheduled cesarean section?
Eitherbecause it was repeated or otherwise.
But if somebody was induced, you know,why was it a medical induction?
and, you know, was there a maternalor fetal indication for that,
trying to understand what went on?
And thenthinking about the mode of delivery,
was it a vaginal deliveryor was it a caesarean section?
(03:33):
So an SVD or a spontaneousvaginal delivery is a spontaneous movement
over the perineum as opposed to,you know, forceps assisted
vaginal deliveryor vacuum assisted vaginal delivery,
which, require interventionthat may have been once again,
because of some sort of fetal concernand a caesarean section,
is a time when there'ssurgical intervention to get the baby out.
(03:56):
And once again, that can be eitherfor maternal or fetal indications.
So the baby's weight,
the percentile, understandingwhat its relationship to gestational age
gives us some sense of what that placentaenvironment was like for the baby.
And and other for the fetusand how they developed.
And if you know,there was any like, for example,
a lot of growth restriction,intrauterine growth restriction,
(04:19):
can produce a lot of small babies,and it can be often
because of a lot of maternal,vascular, issues in the placenta.
So any high blood pressure priorto or during pregnancy.
And this is where the like
the alphabet soupreally starts to get pretty interesting.
Gestational hypertension.
Chronic hypertension.
So gestational hypertension emergesduring pregnancy.
(04:39):
Chronic hypertension is something that either preexisting prior
to pregnancyor in the first 20 weeks of gestation.
Preeclampsia.
Superimposed preeclampsiaon top of chronic hypertension or,
help syndrome or other other wordsyou may end up seeing.
Were there any concerns about blood sugarduring pregnancy?
And that's where gestational diabetescomes in.
(05:01):
Any hospitalizations?
How long was the postpartum stay?
Was there a bit of a readmission.
And met any mental health issues?
Postpartum depression is obviouslysomething that we think a lot about.
So how do we get the conversationstarted with our patients?
I think that, you know,sometimes if we don't have the luxury
of being able to look up obstetric charts,especially sometimes decades later.
(05:22):
How would you ask these questions?
Like, how would you get that conversationstarted?
You know, did they deliver you becausethere was a medical problem with you?
Were the baby were they worried aboutyour baby's sides before or after birth?
Once again, going after this intrauterinegrowth restriction?
Did the baby go home with you, or did thebaby stay in the hospital for more care?
Another measure oflike what outcomes were like?
(05:43):
And actually,
that can also be an indicationto start thinking about gestational age.
That was it was the baby very premature.
And was there anything about thepregnancy, birth or postpartum experience?
I need to know and you may heardifferent kinds of things.
From patients
at that moment,but at least gives them an opportunity
because they may not feelthat their issues followed and followed in
those spaces.
(06:04):
And especially,you know, did they deliver you
because there was a medical problemwith you or the baby?
They, you know, may not rememberwhen you asked that question,
but they may say, oh yeah, that's right.
You know, I my blood pressure was going upand I was getting really sick.
And I have this bad headache and swelling.
And so, you know, I had toI went to the hospital and, you know,
I was on it
and they didn't really thinkthey were delivered early or anything
(06:24):
because they were kind of on term.
But if they're able to sort of share
that story, that's an important piecethat we need to know.
The reason why I'm at a
we're spending time thinking abouthow do we take an obstetric history?
Is there is this relationshipbetween adverse pregnancy outcomes
or opposes the acronymyou often see and cardiovascular risk.
And there is this associationthat we're seeing, in the literature.
(06:48):
And there's really growing data on this,both in retrospective, large scale
retrospective population studies, either
through insurance populations or birthcertificate data and national data.
And also some, secondary
analysis of large prospective studiesthat are also being done.
And there's this emerging relationshipwith, atherosclerotic cardiovascular
(07:10):
disease, as well as some heart failureand valvular disease.
And it's really kind of like a little bit
of a big flag for us to be saying,these patients that have had these
obstetric complications are onesthat are at greater risk later in life.
So about 15% through our latest, national data
(07:31):
that we have of pregnant people experiencehypertensive disorders of pregnancy.
And we already talked a little bitabout all the terms and the alphabet soup,
it is defined right now is greaterthan 140 over 90 during pregnancy.
That is, numberthat's under evolution right now.
But for the purposes of today's talk,this is really something
where all of those complicationsfall into a bucket
(07:54):
once they've been identified as having,
a hypertensive disorders, a pregnancy,or one that's a cardiovascular risk.
Then they sort of end upfollowing in this high risk category.
And the areas that we talkabout, are really, you know, the small
for gestational age or intrauterine growthrestriction, preterm delivery,
hypertensive disorder, pregnancy of any kind, gestational,
(08:16):
hypertension, preeclampsia help syndrome,you know, whatever you want to call it.
And gestational diabetes.
So if we start thinkingabout cardiovascular prevention efforts
over the reproductive life course, I mean,there is this window of opportunity
during pregnancy that can happen, and the immediate postpartum period,
(08:37):
because oftentimes even after delivery,patients are still at risk.
They may develop,
hypertension and developsomething we call postpartum preeclampsia,
yet another opportunityto have a new acronym and a new name
and a new term to understand.
But it means that patients afterthey've delivered develop really high,
they get ill, after the deliveryand have super high blood pressures.
So there can really be a lot of changesin those weeks,
(09:00):
at days and weeks after delivery.
And in fact,there's quite a bit of maternal morbidity
and mortality that happens after thatfirst week of delivery.
Over half really of maternal mortalityhappens after that.
You know, between the one weekand one year after delivery.
So there's a lot of that sort of earlyintervention, right after delivery.
But then after six weeks,where, you know, we're lucky,
(09:23):
you know, if we get more than half of our,of our pregnant persons back
delivering these birthing populationsback for their postpartum visit,
and hopefully, you know,
we've empowered them to make a transitionof care to their primary care doctor
and to really engage in sort of long termand inter pregnancy care.
Eitherwhether they're going to have another,
they're going to have another birthor whether they're going to,
(09:46):
or whether we're going to be just thinkingabout their care in the long term.
And that's where we need to be superaggressive about cardiovascular
interventionsand hypertensive disorders or pregnancy.
I mean, we have talked a lot about sort
of the immediate postpartum transitionand the previous talk.
And in this talk, I was going to focusnot just on that, those period in the
(10:07):
months and years right after pregnancy,but even the decades after pregnancy.
So really looking at midlifecardiovascular risk,
there's just this incredible emerging datalooking at cardiovascular disease,
heart failure,aortic stenosis and mitral regurgitation,
which are actually not usually recognizedin many spaces.
That there's really this group
is really at enormously increasedrisk compared to the general population.
(10:30):
And once again, this is datathat's emerging and we need to learn more.
And we need to learn more about whatthe interventions might be.
When we look at the emerging datafor cardiovascular risk at midlife,
there's this one really well done, studythat's out of the UK.
And they enrolled patientsat midlife women at midlife.
And they found that patientsthat were enrolled
(10:52):
that had a history of hypertensivedisorders of pregnancy
had a much higherrate of hypertension. And,
the number of internet
cardiovascular condition,was also much higher
for patients who had a historyof hypertensive disorders of pregnancy.
And so we really know,like the cardiovascular risk scores,
which lots of primary care doctors love tocalculate, which is not a bad thing.
(11:16):
Don't include any of this,your adverse pregnancy outcomes
and yetwe know that there is so much more risk.
So there needs to be likewe need to be much more aggressive.
And the good news
is that the American Heart Associationand American Stroke Association,
and I'll have come up with,you know, more aggressive guidelines
calling out the adversepregnancy outcomes.
(11:37):
but unfortunately, it's not made it
into like routine,streamlined clinical practice.
And this is and that's concerningbecause we are, we're learning
more and more that this is a populationwe need to be more aggressive with.
How do we address like
how do we get more aggressiveabout cardiovascular prevention?
And honestly,primary care is the place where,
you know, that's pretty much a big pieceof what we do in general medicine.
(12:00):
And, the American Heart Associationhas come up with some fantastic
guidelines,which we call Life's Essential aid.
Just recently, number eight was added,which was sleep,
which is super important for our bodyto rest, recover and rejuvenate.
And that's a big piece of what's going on.
But, just to go through them,you know, eating better, and, you know,
(12:21):
improving the kinds of,you know, the diversity of the foods
we're having, to have more fruitsand vegetables do not have a diet
that's super high in fatand really, becoming more active.
Which is number two,and we recommend 150 minutes a week.
And some of it is just sort of beginningto incorporate
how we do exercise in our lives.
And it's interestingbecause if you look across
(12:42):
cultures in the world,there are many different ways.
The cultures, even in places where it'shard to sort of exercise, as it were,
but they've incorporated, exerciseinto their life.
So smokingcessation is a really, really hot topic.
We've done a fantastic job,
although not a perfect job,and we've not eliminated it.
But, you know, quitting smokingis obviously a huge cardiovascular risk.
(13:03):
We talked about sleep alreadyand really finding a healthy weight
for somebody's size and not stigmatizingpatients for for the size that they are.
And we now, fortunately,have all these amazing medicines
and a lot of like both surgicaland medical interventions to be able
to support patientsto optimize their weight and their health.
And, and, and just because someone isweight, is a challenge.
(13:24):
It doesn't mean we can't work onall the other, ones on the list.
Controlling somebody'scholesterol is also super important.
And actually, it's been called outthe patients
who have a history of preeclampsiaor any of these adverse pregnancy outcomes
really have a great deal of, importance
in starting themon, lipid, their lipid lowering therapy.
Managing bloodsugar is super important as well.
(13:46):
Thosewho have had a history of pre-eclampsia
are at higherrisk for, diabetes in general.
So keeping up the screening testssuper important
and then managing blood pressure,there's just more and more emerging data
that hypertension is such a huge,important number.
One modifiable cardiovascularrisk that we see, and not just in the US
but actually worldwide.
And then there's just two other piecesthat I just want to mention in here
(14:09):
that aren't on the list,but are very important
that we are learning moreand more in this emerging data
about the role of mental healthin our cardiovascular health.
And then also we need to be thinking aboutcontraception methods for our patients
that are that are, you still atreproductive age and able to get pregnant
and really be thinking about longterm, long term solutions for them?
That makes sense and really thinkingabout their thrombotic risk,
(14:30):
as we're counseling themabout their cardiovascular, risk.
And as we think aboutlife's essential aid.
And we and I mentioned, you know,
that I like to think a lotabout mental health and contraception.
But another thing that's incrediblyimportant, that's really the foundation.
The bedrock for all of this ismany of the social determinants of health.
If somebody has a lot of food,housing and transportation and security,
(14:52):
if they don't feel safe in the spacethey're in,
if they're experiencinga lot of structural and systemic racism,
it can really make it much harder to beable to address the issues that they have.
And, it's important to be ableto look at their lived experiences.
So as we look at sort of the pyramidor the inverse pyramid of like,
where do we feed this all into, in terms of our care
(15:15):
is that, you know, our community playsa huge role and in
how we look,how we play out our cardiovascular health.
And that could be from just being ableto get the services that we need
in our community and the supportin our community, and then our health
systems also, can also improve,improve that care.
And, one of the great things, there'sself-monitoring of blood pressure programs
(15:37):
for the postpartum periodand those for, older adults.
Other, you know, adult nonreproductive age adults.
And we have a number of postpartumtransition care clinics,
which is also really fantastic.
And actually condition
I've had one, here at Brigham and Women'sfor the last more than 13 years.
And then in the community,either through churches or the YMCA or
(15:58):
any sort of outreach, there's been amazinghealth coaching that's done a great job.
And so as health care professionals,
we really need to be aggressiveabout addressing stage one hypertension.
We need to address obesity,as I mentioned, previously.
And then,we need to be able to look for a more
aggressive screening measureswhich may include calcium risk scores.
(16:19):
And really focusing on life'sessential aid as being lifestyle issues
and thinking about themin the full context.
What do we have for providersto support them?
What kinds of things are out there?
One example is, a multimodal
educational tool which is availablefor free on the web right now.
I helped developit with, the Preeclampsia Foundation,
(16:39):
the Society of Maternal Fetal Medicine,and the International Society
for the Study of Hypertensionand Pregnancy, using a number of voices
and groups and key
stakeholders from across the countryand actually across the world,
that number in in greater than hundreds, and, thinking about hearing voices
and thinking about what what patients needafter that, immediate period.
(17:03):
So just sort of acknowledgingthat somebody what happens now
here is just sort of acknowledgingthat there's been a lot of change.
It's been traumatic.
And you'd be surprisedeven patients years beyond,
welcome the opportunityto talk about those issues.
And then another pointmaking the point that they're at greater
risk for cardiovascularpoor cardiovascular outcomes.
And then the next piece,is a piece of ability
(17:24):
to tell your birth story,which is something that
we've really learned from,some qualitative, work with patients.
And so being able to namewhat their issues are,
or what they experiencedis very important.
And then there's a link to learn abouthow to check your blood
pressure during pregnancy and,you know, days, weeks and months beyond.
And that's also available for freeon the Preeclampsia Foundation.
(17:46):
And then, a little bit of a plugfor primary care provider.
And there's shortagesall over the country.
And, not all spaces and all groups feelthat they have access to primary care.
So this is the only placethat it's mentioned.
But reallythat if they do have the opportunity
to have a primary care provider, this is agreat person for them to engage with.
They are, really fantastic at being ableto help patients get to their best self,
(18:08):
by making diagnoses
and also getting them to, collaboratewith specialists that they need.
And if patients feel they need some helpwith asking questions,
there's some conversation startersto sort of talk to their care providers,
the third, page on the web page,it can be printed or it can be on the web.
Is really for those, you know, sort of,you know, months and years
after pregnancy,just some touchstones of things
(18:30):
the patients need in many ways,adverse pregnancy outcomes
and the hypertensive disordersare a great opportunity
to really empower patientsto put themselves higher on that list.
They understand that they're at riskfor poor health outcomes then,
and that in that intervening in this waymay actually help them.
Potentially.
We hope,that that actually can empower them to do
(18:52):
to do the interventionsand the lifestyle changes that they need.
So some key elements of this is that it'swritten in gender neutral language
to make it sort of openand engaging for all populations
and easy to understand at the sixth gradereading level and Flesh Kincaid test.
And it's availablein both English and Spanish.
At that level, it's interactive,it's empowering, and it really only
(19:12):
has the essential information they need.
Hi Marika,
it's great to see youand thank you so much for joining us.
For this maternal heartbeat.
You and I first metwhen I was caring for you back
at the height of Covidin the fall of 2020.
I met you after your third pregnancy,and you would have already had two
(19:35):
previous pregnancies that had,superimposed severe preeclampsia with,
in the first one,you developed late preterm preeclampsia
about 36 weeks,and a second pregnancy happened postpartum
both times with really highblood pressure is difficult to control.
And then in your third pregnancy,you induced at 38 weeks
and then once againhad postpartum preeclampsia.
(19:56):
And in that pregnancy,you were really had a lot of very high
uncontrolled blood pressures therein what we would call the severe range.
So just sharing your story
about at that moment,sort of what was going on, for you.
Sure.
First I have to say thank you, thoughat that time, I was very nervous.
(20:17):
I was scared,having already had lost my dad.
I knew the severity of it.
I think that one of the most importantthings that can be done to help
patients like myself is to build trust,And is to educate.
And I feel like rather than shaming
and blaming, which I think can comefrom those type of experiences,
the best thing to dois to begin with listening.
(20:39):
And what I would have wanted to hearis that
here's how we're going to support youthrough this.
Here's what this is going to look like.
This might be somethingthat's a challenge,
but this is what we can doto work through this with you.
And, I didn't feel like I got thatand I didn't feel
invested in as an individualbecause I'm a multitasker already.
I felt the need to show that I could do itand take care of it,
(21:03):
but when I would express myself,I felt, I'd say ashamed, right?
I felt, thoughI wasn't keeping up with something
that I should have been ableto keep up with, knowing that I had three
children under the age of five,you know, at that time,
and had a a very busy lifestylethat I was a hard worker,
that I had a husband at the timethat was a very hard worker,
(21:27):
and a lot of it rested on me
being at home and being an individualthat had the schedule that I had.
I felt that it was a lot of shamethat was there.
As care providers,
it's incredibly important that welisten to this and we start being creative
because there are other medicinesthat you can use that are reasonably
well understood in breastfeeding,or that the or that the, the profile
(21:48):
is, that are usedis, being increased substantially.
And so that's actually where reallybehooves us to really individualize care.
And those patients with sortof more complicated circumstances,
we just need to roll up our sleeves
and really startthinking about the complexities.
And then once again,listening to patients about what?
About what it is that they need.
We've already talked a little bitabout how you weren't
(22:11):
you did not feel heard or you didn'tfeel like you were trusted or understood.
And, you know,there were a number of things
that we did together to try to sort ofhelp ease your care, especially
as you rolled off my careand moved onto your primary care provider.
I spent some energies, communicatingthe issues that I was concerned about.
And, and when you went, you've gotyou had your list.
(22:31):
Can you just talk a little bitabout what you think
other providers might want to knowwhen they care for these patients?
Sure.
I think in additionto just listening, right.
And having that empathetic ear
and understanding that there are livedexperiences that might differ.
At the end of the day, it's a matter of,
you being educated and understandingthe cultural responsiveness.
(22:54):
You know, that is there.
Patients like myself, we willactively engage when I feel like you have,
that if
if I feel like you have my, most important needs at hand
and that if I feel like
you are taking my concerns to heartand that you are actively understanding
what it is that I'm going through, thenI'm going to be more open to listening
(23:16):
and to trusting, as opposed to feelinglike I might need to be on the defense.
So I think as as those of usthat are in health care as physicians,
you know, midwives, you know, communityhealth workers, jewelers, whatever
our role is,if we're able to acknowledge,
you know, the barriersand the concerns that we have,
hopefully we can help,
you know, bridge that trust and say,you know, I don't have your experience,
(23:38):
but I can only imagine what it might belike, your transition to primary care.
We had gotten your blood pressureunder control.
For the most part.
We were trying to move forwardand think smart about what your health
would be moving forward.
And, can you talk a little bit about,you know, either, you know,
action itemsthat came out of our experience together,
working with your primary caredoctor that you're working on now
(24:00):
and you continue to workon, moving forward.
I spent much of my life in fear.
I wasn't sure when I got to my 40swhat that was going to look like.
I'm here with my three children,and so a lot of that pressure
that I was feeling of, am I going to make
it is the same thing going to happen to methat happened with my, father.
I want to be around.
I lived in a lot of fear,and there was pressure
(24:20):
that was on me because I knewthat my pressure was not under control.
It wasn't until I met you and I'm like,it was like to be with like
you twinkle the notes.
Remember that show that it.
And I want to sayit was just like automatic.
But it didn't take longto get my pressure under control
because you were well versedand understanding
what we needed to try, what we could try
(24:42):
and it was the first timethat I felt like, wow, okay,
I can,
you know,
I can trust and understand that this isgoing to be taken into consideration.
I also have like a cuff. Right?
So I'm taking my pressure. I'mmaking sure that I check it.
And I mean, that's thanks to you.She's asking me, did you take that?
You take your medication,did you check your pressure?
And so your voice is like right herein my ear of did you check your pressure?
(25:04):
Did you check your pressure?Get your cuff out. Just check it.
You don't have to make that besomething that is going to stress you too.
But just make sure you check ita couple of times.
And so I do that and that's continued on.
I set an alarm and I used to set it beforeand it just snoozed
because I was taking care of the kids.
But I'm more present and knowing, listen,if I want to be here
in the long term, that simple thing of set
(25:25):
the alarm, make sure that you have a timethat works for you.
Yeah, let's find the time that worksand set the alarm and take it.
And so I still do that.
I have a schedule that works for me whereI take my medication, in the morning.
Now, I take a medication in the evening,and it is not something that I am missing,
and I'm able to stay true to a schedulethat works for me.
(25:48):
So some important thingswe've talked about,
in the time that we've been withtogether, is to be able to understand
how a patient's birth story and pregnancycomplications are important
for understanding laterlife, cardiovascular disease.
And that really in a routine visitsand many different settings
and almost every setting that counselingabout heart healthy lifestyle behaviors
(26:09):
and, to decrease cardiometabolic riskand really thinking about lactation,
contraception, hypertensive medicationsand mental health are super important.
And during the care transitionfrom obstetric to primary care
or in any care transition,we need to think about lived experiences.
So permanence of health.
And they should really be a priorityof our care.
That we give.
And whenever setting we'rein, and primary care providers
(26:32):
are, you know, this is a great opportunityfor generalists to really be amplified.
And and those can bein many different settings.
And I would also include,you know, our community
nurse aides, our community health workers,our dual population,
our advanced practice providers,and especially those that are working
very hard in rural communities.
And then really, we need to think aboutcardiovascular disease prediction scores
(26:53):
and the fact that they are wonderfulon many levels, but they don't include
adverse pregnancy outcomes.And so they really don't
adequately predictcardiovascular risks in those patients.
And then there's this growing knowledgeof midlife women that show increased risk
for cardiovascular diseasefailure and valvular disease,
and then aggressivecardiovascular prevention.
Using life'sessential aid as a as a bedrock of.
(27:15):
This becomes even more important forpatients after adverse pregnancy outcomes.
So thank you very muchfor joining me today.
For more additional resources,please reach out to the AHA's web pages.
They have incredible numbers of fantasticresources
to be able to help you in your journeyfor cardiovascular prevention.
Hi, I
am DoctorAnn Celi, and I'm coming in to you
from Brigham and Women's Hospitaland Harvard Medical School here in Boston.
And today I'm talking about sort ofhow we can use obstetric histories
to really capitalize on addressinglonger term cardiovascular risk.
So I really like to think about thisas sort of thinking beyond birth
(00:35):
and longer term opportunitiesto improve cardiometabolic health.
And this project was, supported
by funding from Merckthrough its Merck for mothers program.
The recommendations and opinionspresented by our guest speakers
may not represent the official positionof the American Heart Association.
The materials are for educational purposesonly and do not constitute
(00:56):
an endorsementor instruction by AHA or ASA.
The AHA / ASA doesnot endorse any product or device.
I have nothing to disclose.
And Marika Hamilton, who's my patient,who's also going to appear on this,
has nothing to disclose either.
So our learning objectives for todayinclude, we're going to be talking about
the importance of an obstetric history,what it means suggested questions
(01:19):
and conversation startersto help obtain this history from patients.
We're going to try to identify the keyelements of the obstetric history
that signal later life
cardiovascular risk to guidecardiovascular disease prevention efforts.
Recognize the role of disparitiesand social determinants of health
during care transition, and develop
strategies to connect patientsto available resources.
(01:42):
Incorporate obtaining an obstetric historyand counseling strategies to decrease
cardiac anabolic risk
by a lifestyle change, including toolslike Life's Essential eight
and a routine visit and the months, years,and decades after pregnancy.
So this is not ACOG approved,but these are acronyms that many
physicians, caregivers, doulas,community health workers, nurses see.
(02:03):
And it can seem a little bitlike alphabet soup
because there's just so many lettersand we don't really understand
where they come from.
So I was going to hope to sort of talk
about some of the obstetric lingo,to be able to better understand
and obstetrical historyif you're reading charts.
And also just to geta better understanding of what
we're looking for and what we needin terms of the care for our patients.
(02:24):
So it's important to try to understanda patient's birth story.
If they've if they're somebodywho's given birth at their Paris, and,
one of the one of the important earlythings is like, how far along were they
and their pregnancyand what was their gestational age?
And was the baby did the babygo to the neonatal intensive care unit,
which, is a marker of sort of diseaselevel?
(02:46):
You know, if somebody was born early,a baby was born early.
That's obviously,you know, incredibly concerning
and may have eithera fetal or maternal reason for that.
And if the baby is in the queue,
then that's really sort of a markerof what the birth outcome was.
And that's something,you know, to obviously,
the ultimate product of a pregnancyis we want a healthy baby.
So look at baby'soutcome is quite important.
The next thing we want to look atis, was the labor, induced or was it
(03:11):
spontaneous or was it scheduled, like,you know, a scheduled cesarean section?
Eitherbecause it was repeated or otherwise.
But if somebody was induced, you know,why was it a medical induction?
and, you know, was there a maternalor fetal indication for that,
trying to understand what went on?
And thenthinking about the mode of delivery,
was it a vaginal deliveryor was it a caesarean section?
(03:33):
So an SVD or a spontaneousvaginal delivery is a spontaneous movement
over the perineum as opposed to,you know, forceps assisted
vaginal deliveryor vacuum assisted vaginal delivery,
which, require interventionthat may have been once again,
because of some sort of fetal concernand a caesarean section,
is a time when there'ssurgical intervention to get the baby out.
(03:56):
And once again, that can be eitherfor maternal or fetal indications.
So the baby's weight,
the percentile, understandingwhat its relationship to gestational age
gives us some sense of what that placentaenvironment was like for the baby.
And and other for the fetusand how they developed.
And if you know,there was any like, for example,
a lot of growth restriction,intrauterine growth restriction,
(04:19):
can produce a lot of small babies,and it can be often
because of a lot of maternal,vascular, issues in the placenta.
So any high blood pressure priorto or during pregnancy.
And this is where the like
the alphabet soupreally starts to get pretty interesting.
Gestational hypertension.
Chronic hypertension.
So gestational hypertension emergesduring pregnancy.
(04:39):
Chronic hypertension is something that either preexisting prior
to pregnancyor in the first 20 weeks of gestation.
Preeclampsia.
Superimposed preeclampsiaon top of chronic hypertension or,
help syndrome or other other wordsyou may end up seeing.
Were there any concerns about blood sugarduring pregnancy?
And that's where gestational diabetescomes in.
(05:01):
Any hospitalizations?
How long was the postpartum stay?
Was there a bit of a readmission.
And met any mental health issues?
Postpartum depression is obviouslysomething that we think a lot about.
So how do we get the conversationstarted with our patients?
I think that, you know,sometimes if we don't have the luxury
of being able to look up obstetric charts,especially sometimes decades later.
(05:22):
How would you ask these questions?
Like, how would you get that conversationstarted?
You know, did they deliver you becausethere was a medical problem with you?
Were the baby were they worried aboutyour baby's sides before or after birth?
Once again, going after this intrauterinegrowth restriction?
Did the baby go home with you, or did thebaby stay in the hospital for more care?
Another measure oflike what outcomes were like?
(05:43):
And actually,
that can also be an indicationto start thinking about gestational age.
That was it was the baby very premature.
And was there anything about thepregnancy, birth or postpartum experience?
I need to know and you may heardifferent kinds of things.
From patients
at that moment,but at least gives them an opportunity
because they may not feelthat their issues followed and followed in
those spaces.
(06:04):
And especially,you know, did they deliver you
because there was a medical problemwith you or the baby?
They, you know, may not rememberwhen you asked that question,
but they may say, oh yeah, that's right.
You know, I my blood pressure was going upand I was getting really sick.
And I have this bad headache and swelling.
And so, you know, I had toI went to the hospital and, you know,
I was on it
and they didn't really thinkthey were delivered early or anything
(06:24):
because they were kind of on term.
But if they're able to sort of share
that story, that's an important piecethat we need to know.
The reason why I'm at a
we're spending time thinking abouthow do we take an obstetric history?
Is there is this relationshipbetween adverse pregnancy outcomes
or opposes the acronymyou often see and cardiovascular risk.
And there is this associationthat we're seeing, in the literature.
(06:48):
And there's really growing data on this,both in retrospective, large scale
retrospective population studies, either
through insurance populations or birthcertificate data and national data.
And also some, secondary
analysis of large prospective studiesthat are also being done.
And there's this emerging relationshipwith, atherosclerotic cardiovascular
(07:10):
disease, as well as some heart failureand valvular disease.
And it's really kind of like a little bit
of a big flag for us to be saying,these patients that have had these
obstetric complications are onesthat are at greater risk later in life.
So about 15% through our latest, national data
(07:31):
that we have of pregnant people experiencehypertensive disorders of pregnancy.
And we already talked a little bitabout all the terms and the alphabet soup,
it is defined right now is greaterthan 140 over 90 during pregnancy.
That is, numberthat's under evolution right now.
But for the purposes of today's talk,this is really something
where all of those complicationsfall into a bucket
(07:54):
once they've been identified as having,
a hypertensive disorders, a pregnancy,or one that's a cardiovascular risk.
Then they sort of end upfollowing in this high risk category.
And the areas that we talkabout, are really, you know, the small
for gestational age or intrauterine growthrestriction, preterm delivery,
hypertensive disorder, pregnancy of any kind, gestational,
(08:16):
hypertension, preeclampsia help syndrome,you know, whatever you want to call it.
And gestational diabetes.
So if we start thinkingabout cardiovascular prevention efforts
over the reproductive life course, I mean,there is this window of opportunity
during pregnancy that can happen, and the immediate postpartum period,
(08:37):
because oftentimes even after delivery,patients are still at risk.
They may develop,
hypertension and developsomething we call postpartum preeclampsia,
yet another opportunityto have a new acronym and a new name
and a new term to understand.
But it means that patients afterthey've delivered develop really high,
they get ill, after the deliveryand have super high blood pressures.
So there can really be a lot of changesin those weeks,
(09:00):
at days and weeks after delivery.
And in fact,there's quite a bit of maternal morbidity
and mortality that happens after thatfirst week of delivery.
Over half really of maternal mortalityhappens after that.
You know, between the one weekand one year after delivery.
So there's a lot of that sort of earlyintervention, right after delivery.
But then after six weeks,where, you know, we're lucky,
(09:23):
you know, if we get more than half of our,of our pregnant persons back
delivering these birthing populationsback for their postpartum visit,
and hopefully, you know,
we've empowered them to make a transitionof care to their primary care doctor
and to really engage in sort of long termand inter pregnancy care.
Eitherwhether they're going to have another,
they're going to have another birthor whether they're going to,
(09:46):
or whether we're going to be just thinkingabout their care in the long term.
And that's where we need to be superaggressive about cardiovascular
interventionsand hypertensive disorders or pregnancy.
I mean, we have talked a lot about sort
of the immediate postpartum transitionand the previous talk.
And in this talk, I was going to focusnot just on that, those period in the
(10:07):
months and years right after pregnancy,but even the decades after pregnancy.
So really looking at midlifecardiovascular risk,
there's just this incredible emerging datalooking at cardiovascular disease,
heart failure,aortic stenosis and mitral regurgitation,
which are actually not usually recognizedin many spaces.
That there's really this group
is really at enormously increasedrisk compared to the general population.
(10:30):
And once again, this is datathat's emerging and we need to learn more.
And we need to learn more about whatthe interventions might be.
When we look at the emerging datafor cardiovascular risk at midlife,
there's this one really well done, studythat's out of the UK.
And they enrolled patientsat midlife women at midlife.
And they found that patientsthat were enrolled
(10:52):
that had a history of hypertensivedisorders of pregnancy
had a much higherrate of hypertension. And,
the number of internet
cardiovascular condition,was also much higher
for patients who had a historyof hypertensive disorders of pregnancy.
And so we really know,like the cardiovascular risk scores,
which lots of primary care doctors love tocalculate, which is not a bad thing.
(11:16):
Don't include any of this,your adverse pregnancy outcomes
and yetwe know that there is so much more risk.
So there needs to be likewe need to be much more aggressive.
And the good news
is that the American Heart Associationand American Stroke Association,
and I'll have come up with,you know, more aggressive guidelines
calling out the adversepregnancy outcomes.
(11:37):
but unfortunately, it's not made it
into like routine,streamlined clinical practice.
And this is and that's concerningbecause we are, we're learning
more and more that this is a populationwe need to be more aggressive with.
How do we address like
how do we get more aggressiveabout cardiovascular prevention?
And honestly,primary care is the place where,
you know, that's pretty much a big pieceof what we do in general medicine.
(12:00):
And, the American Heart Associationhas come up with some fantastic
guidelines,which we call Life's Essential aid.
Just recently, number eight was added,which was sleep,
which is super important for our bodyto rest, recover and rejuvenate.
And that's a big piece of what's going on.
But, just to go through them,you know, eating better, and, you know,
(12:21):
improving the kinds of,you know, the diversity of the foods
we're having, to have more fruitsand vegetables do not have a diet
that's super high in fatand really, becoming more active.
Which is number two,and we recommend 150 minutes a week.
And some of it is just sort of beginningto incorporate
how we do exercise in our lives.
And it's interestingbecause if you look across
(12:42):
cultures in the world,there are many different ways.
The cultures, even in places where it'shard to sort of exercise, as it were,
but they've incorporated, exerciseinto their life.
So smokingcessation is a really, really hot topic.
We've done a fantastic job,
although not a perfect job,and we've not eliminated it.
But, you know, quitting smokingis obviously a huge cardiovascular risk.
(13:03):
We talked about sleep alreadyand really finding a healthy weight
for somebody's size and not stigmatizingpatients for for the size that they are.
And we now, fortunately,have all these amazing medicines
and a lot of like both surgicaland medical interventions to be able
to support patientsto optimize their weight and their health.
And, and, and just because someone isweight, is a challenge.
(13:24):
It doesn't mean we can't work onall the other, ones on the list.
Controlling somebody'scholesterol is also super important.
And actually, it's been called outthe patients
who have a history of preeclampsiaor any of these adverse pregnancy outcomes
really have a great deal of, importance
in starting themon, lipid, their lipid lowering therapy.
Managing bloodsugar is super important as well.
(13:46):
Thosewho have had a history of pre-eclampsia
are at higherrisk for, diabetes in general.
So keeping up the screening testssuper important
and then managing blood pressure,there's just more and more emerging data
that hypertension is such a huge,important number.
One modifiable cardiovascularrisk that we see, and not just in the US
but actually worldwide.
And then there's just two other piecesthat I just want to mention in here
(14:09):
that aren't on the list,but are very important
that we are learning moreand more in this emerging data
about the role of mental healthin our cardiovascular health.
And then also we need to be thinking aboutcontraception methods for our patients
that are that are, you still atreproductive age and able to get pregnant
and really be thinking about longterm, long term solutions for them?
That makes sense and really thinkingabout their thrombotic risk,
(14:30):
as we're counseling themabout their cardiovascular, risk.
And as we think aboutlife's essential aid.
And we and I mentioned, you know,
that I like to think a lotabout mental health and contraception.
But another thing that's incrediblyimportant, that's really the foundation.
The bedrock for all of this ismany of the social determinants of health.
If somebody has a lot of food,housing and transportation and security,
(14:52):
if they don't feel safe in the spacethey're in,
if they're experiencinga lot of structural and systemic racism,
it can really make it much harder to beable to address the issues that they have.
And, it's important to be ableto look at their lived experiences.
So as we look at sort of the pyramidor the inverse pyramid of like,
where do we feed this all into, in terms of our care
(15:15):
is that, you know, our community playsa huge role and in
how we look,how we play out our cardiovascular health.
And that could be from just being ableto get the services that we need
in our community and the supportin our community, and then our health
systems also, can also improve,improve that care.
And, one of the great things, there'sself-monitoring of blood pressure programs
(15:37):
for the postpartum periodand those for, older adults.
Other, you know, adult nonreproductive age adults.
And we have a number of postpartumtransition care clinics,
which is also really fantastic.
And actually condition
I've had one, here at Brigham and Women'sfor the last more than 13 years.
And then in the community,either through churches or the YMCA or
(15:58):
any sort of outreach, there's been amazinghealth coaching that's done a great job.
And so as health care professionals,
we really need to be aggressiveabout addressing stage one hypertension.
We need to address obesity,as I mentioned, previously.
And then,we need to be able to look for a more
aggressive screening measureswhich may include calcium risk scores.
(16:19):
And really focusing on life'sessential aid as being lifestyle issues
and thinking about themin the full context.
What do we have for providersto support them?
What kinds of things are out there?
One example is, a multimodal
educational tool which is availablefor free on the web right now.
I helped developit with, the Preeclampsia Foundation,
(16:39):
the Society of Maternal Fetal Medicine,and the International Society
for the Study of Hypertensionand Pregnancy, using a number of voices
and groups and key
stakeholders from across the countryand actually across the world,
that number in in greater than hundreds, and, thinking about hearing voices
and thinking about what what patients needafter that, immediate period.
(17:03):
So just sort of acknowledgingthat somebody what happens now
here is just sort of acknowledgingthat there's been a lot of change.
It's been traumatic.
And you'd be surprisedeven patients years beyond,
welcome the opportunityto talk about those issues.
And then another pointmaking the point that they're at greater
risk for cardiovascularpoor cardiovascular outcomes.
And then the next piece,is a piece of ability
(17:24):
to tell your birth story,which is something that
we've really learned from,some qualitative, work with patients.
And so being able to namewhat their issues are,
or what they experiencedis very important.
And then there's a link to learn abouthow to check your blood
pressure during pregnancy and,you know, days, weeks and months beyond.
And that's also available for freeon the Preeclampsia Foundation.
(17:46):
And then, a little bit of a plugfor primary care provider.
And there's shortagesall over the country.
And, not all spaces and all groups feelthat they have access to primary care.
So this is the only placethat it's mentioned.
But reallythat if they do have the opportunity
to have a primary care provider, this is agreat person for them to engage with.
They are, really fantastic at being ableto help patients get to their best self,
(18:08):
by making diagnoses
and also getting them to, collaboratewith specialists that they need.
And if patients feel they need some helpwith asking questions,
there's some conversation startersto sort of talk to their care providers,
the third, page on the web page,it can be printed or it can be on the web.
Is really for those, you know, sort of,you know, months and years
after pregnancy,just some touchstones of things
(18:30):
the patients need in many ways,adverse pregnancy outcomes
and the hypertensive disordersare a great opportunity
to really empower patientsto put themselves higher on that list.
They understand that they're at riskfor poor health outcomes then,
and that in that intervening in this waymay actually help them.
Potentially.
We hope,that that actually can empower them to do
(18:52):
to do the interventionsand the lifestyle changes that they need.
So some key elements of this is that it'swritten in gender neutral language
to make it sort of openand engaging for all populations
and easy to understand at the sixth gradereading level and Flesh Kincaid test.
And it's availablein both English and Spanish.
At that level, it's interactive,it's empowering, and it really only
(19:12):
has the essential information they need.
Hi Marika,
it's great to see youand thank you so much for joining us.
For this maternal heartbeat.
You and I first metwhen I was caring for you back
at the height of Covidin the fall of 2020.
I met you after your third pregnancy,and you would have already had two
(19:35):
previous pregnancies that had,superimposed severe preeclampsia with,
in the first one,you developed late preterm preeclampsia
about 36 weeks,and a second pregnancy happened postpartum
both times with really highblood pressure is difficult to control.
And then in your third pregnancy,you induced at 38 weeks
and then once againhad postpartum preeclampsia.
(19:56):
And in that pregnancy,you were really had a lot of very high
uncontrolled blood pressures therein what we would call the severe range.
So just sharing your story
about at that moment,sort of what was going on, for you.
Sure.
First I have to say thank you, thoughat that time, I was very nervous.
(20:17):
I was scared,having already had lost my dad.
I knew the severity of it.
I think that one of the most importantthings that can be done to help
patients like myself is to build trust,And is to educate.
And I feel like rather than shaming
and blaming, which I think can comefrom those type of experiences,
the best thing to dois to begin with listening.
(20:39):
And what I would have wanted to hearis that
here's how we're going to support youthrough this.
Here's what this is going to look like.
This might be somethingthat's a challenge,
but this is what we can doto work through this with you.
And, I didn't feel like I got thatand I didn't feel
invested in as an individualbecause I'm a multitasker already.
I felt the need to show that I could do itand take care of it,
(21:03):
but when I would express myself,I felt, I'd say ashamed, right?
I felt, thoughI wasn't keeping up with something
that I should have been ableto keep up with, knowing that I had three
children under the age of five,you know, at that time,
and had a a very busy lifestylethat I was a hard worker,
that I had a husband at the timethat was a very hard worker,
(21:27):
and a lot of it rested on me
being at home and being an individualthat had the schedule that I had.
I felt that it was a lot of shamethat was there.
As care providers,
it's incredibly important that welisten to this and we start being creative
because there are other medicinesthat you can use that are reasonably
well understood in breastfeeding,or that the or that the, the profile
(21:48):
is, that are usedis, being increased substantially.
And so that's actually where reallybehooves us to really individualize care.
And those patients with sortof more complicated circumstances,
we just need to roll up our sleeves
and really startthinking about the complexities.
And then once again,listening to patients about what?
About what it is that they need.
We've already talked a little bitabout how you weren't
(22:11):
you did not feel heard or you didn'tfeel like you were trusted or understood.
And, you know,there were a number of things
that we did together to try to sort ofhelp ease your care, especially
as you rolled off my careand moved onto your primary care provider.
I spent some energies, communicatingthe issues that I was concerned about.
And, and when you went, you've gotyou had your list.
(22:31):
Can you just talk a little bitabout what you think
other providers might want to knowwhen they care for these patients?
Sure.
I think in additionto just listening, right.
And having that empathetic ear
and understanding that there are livedexperiences that might differ.
At the end of the day, it's a matter of,
you being educated and understandingthe cultural responsiveness.
(22:54):
You know, that is there.
Patients like myself, we willactively engage when I feel like you have,
that if
if I feel like you have my, most important needs at hand
and that if I feel like
you are taking my concerns to heartand that you are actively understanding
what it is that I'm going through, thenI'm going to be more open to listening
(23:16):
and to trusting, as opposed to feelinglike I might need to be on the defense.
So I think as as those of usthat are in health care as physicians,
you know, midwives, you know, communityhealth workers, jewelers, whatever
our role is,if we're able to acknowledge,
you know, the barriersand the concerns that we have,
hopefully we can help,
you know, bridge that trust and say,you know, I don't have your experience,
(23:38):
but I can only imagine what it might belike, your transition to primary care.
We had gotten your blood pressureunder control.
For the most part.
We were trying to move forwardand think smart about what your health
would be moving forward.
And, can you talk a little bit about,you know, either, you know,
action itemsthat came out of our experience together,
working with your primary caredoctor that you're working on now
(24:00):
and you continue to workon, moving forward.
I spent much of my life in fear.
I wasn't sure when I got to my 40swhat that was going to look like.
I'm here with my three children,and so a lot of that pressure
that I was feeling of, am I going to make
it is the same thing going to happen to methat happened with my, father.
I want to be around.
I lived in a lot of fear,and there was pressure
(24:20):
that was on me because I knewthat my pressure was not under control.
It wasn't until I met you and I'm like,it was like to be with like
you twinkle the notes.
Remember that show that it.
And I want to sayit was just like automatic.
But it didn't take longto get my pressure under control
because you were well versedand understanding
what we needed to try, what we could try
(24:42):
and it was the first timethat I felt like, wow, okay,
I can,
you know,
I can trust and understand that this isgoing to be taken into consideration.
I also have like a cuff. Right?
So I'm taking my pressure. I'mmaking sure that I check it.
And I mean, that's thanks to you.She's asking me, did you take that?
You take your medication,did you check your pressure?
And so your voice is like right herein my ear of did you check your pressure?
(25:04):
Did you check your pressure?Get your cuff out. Just check it.
You don't have to make that besomething that is going to stress you too.
But just make sure you check ita couple of times.
And so I do that and that's continued on.
I set an alarm and I used to set it beforeand it just snoozed
because I was taking care of the kids.
But I'm more present and knowing, listen,if I want to be here
in the long term, that simple thing of set
(25:25):
the alarm, make sure that you have a timethat works for you.
Yeah, let's find the time that worksand set the alarm and take it.
And so I still do that.
I have a schedule that works for me whereI take my medication, in the morning.
Now, I take a medication in the evening,and it is not something that I am missing,
and I'm able to stay true to a schedulethat works for me.
(25:48):
So some important thingswe've talked about,
in the time that we've been withtogether, is to be able to understand
how a patient's birth story and pregnancycomplications are important
for understanding laterlife, cardiovascular disease.
And that really in a routine visitsand many different settings
and almost every setting that counselingabout heart healthy lifestyle behaviors
(26:09):
and, to decrease cardiometabolic riskand really thinking about lactation,
contraception, hypertensive medicationsand mental health are super important.
And during the care transitionfrom obstetric to primary care
or in any care transition,we need to think about lived experiences.
So permanence of health.
And they should really be a priorityof our care.
That we give.
And whenever setting we'rein, and primary care providers
(26:32):
are, you know, this is a great opportunityfor generalists to really be amplified.
And and those can bein many different settings.
And I would also include,you know, our community
nurse aides, our community health workers,our dual population,
our advanced practice providers,and especially those that are working
very hard in rural communities.
And then really, we need to think aboutcardiovascular disease prediction scores
(26:53):
and the fact that they are wonderfulon many levels, but they don't include
adverse pregnancy outcomes.And so they really don't
adequately predictcardiovascular risks in those patients.
And then there's this growing knowledgeof midlife women that show increased risk
for cardiovascular diseasefailure and valvular disease,
and then aggressivecardiovascular prevention.
Using life'sessential aid as a as a bedrock of.
(27:15):
This becomes even more important forpatients after adverse pregnancy outcomes.
So thank you very muchfor joining me today.
For more additional resources,please reach out to the AHA's web pages.
They have incredible numbers of fantasticresources
to be able to help you in your journeyfor cardiovascular prevention.
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